From the time she was 17, Michele Prigo never missed a Pap smear. She knew the annual check could catch signs of cervical cancer, yet year after year, she was only vaguely mindful of the involvement of a sexually transmitted virus. The sex-ed she got in the 1990s was mostly a lecture trying to frighten the libido out of her, with an onscreen horror show of sore-covered genitalia. She admits she didn't always insist her boyfriends use condoms. Why would she? None of them reminded her of the scary sex-ed pictures. "They all looked perfectly healthy," she says.
When the first cervical-cancer vaccine entered the market seven years ago, Prigo was just over the age limit of 26. But even if she had been younger, she says she probably wouldn't have gotten the shot. "No one I knew ever had any STDs. It didn't fit into the model of where I was at and the crowd I was running with," says Prigo, who is now 38 and lives in New York City. When she reached her early 30s, her Paps were still popping up normal. But her doctor ran a screen for human papillomavirus (HPV), the virus that causes cervical cancer. Lo and behold, there it was.
Chances are, Prigo picked up HPV pretty soon after she started having sex. It's so common that the vast majority of the population will be infected during their lives. Most of the dozens of strains do nothing, quietly retreating and vanishing on their own. But a few of them work their way into normal tissue, eventually turning healthy cells into cancer. Prigo tested positive for a high-risk strain.
When she thinks about the day doctors burned off part of her cervix — she recalls "smoke and the ever so slight smell of burning flesh" — Prigo is dumbfounded to explain why she didn't embrace the HPV vaccine earlier and why so many women and girls continue to avoid it. Approved in 2006, the shot was initially hailed as a victory against a major killer of women worldwide. "If that's not a break through, I don't know what is," one jubilant doctor told ABC news at the time.
About 40 strains of genital HPV circulate in the human population, but of those, just two (6 and 11) are responsible for about 90 percent of genital warts and two more (16 and 18) for 70 percent of cervical cancers and many cases of vaginal, anal, and throat cancer. Those four strains are the target of Gardasil, which is made by Merck. A second vaccine from GlaxoSmithKline, Cervarix, targets 16 and 18.
Together, these shots should have essentially freed the current generation of young women from the threat of HPV-associated cancers and genital warts. But this isn't the case. Only about 54 percent of teenage girls are receiving even one dose, which gives you partial protection, and a mere one-third get the three shots necessary for full effectiveness. Public-health experts use terms like extremely distressing and depressing to describe the numbers. Cervical cancer still strikes more than 10,000 women in the United States each year. And earlier this year, a government report found that while cancer mortality rates overall are declining, deaths from some HPV-driven tumors are ticking upward.
"I am very surprised that a safe, effective, anticancer vaccine is doing this poorly," says Anne Schuchat, MD, assistant surgeon general, U.S. Public Health Service. "I certainly hoped that by 2013, women in their 20s would have already gotten the vaccine."
So why aren't people clamoring for an anticancer shot? Because somewhere on the road to disease prevention, the HPV vaccine came to embody everything that's wrong with America, at least in some circles — premarital promiscuity, Big Pharma greed, and government control. "The vaccine acquired this kind of identity as an STD shot for young girls," says Dan Kahan, a professor of law and psychology at Yale Law School. Meanwhile, unfounded rumors about the shot's safety and effectiveness have spread. Not the lifesaving image developers envisioned.
The HPV vaccine isn't the first shot against a sexually transmitted cancer. Immunization for hepatitis B, which can cause liver cancer, has been around since 1981 without much controversy. Nearly 90 percent of children are protected from the virus, mostly because the shot is included in the routine round of infant vaccines. The HPV vaccine is at a disadvantage because the immunization rates for adolescents always lag behind those for toddlers. But consider a vaccine that appeared about the same time as Gardasil: A shot given to middle schoolers that protects against meningococcal meningitis. The latest figures indicate that about 74 percent of teenagers who should be getting the shot are, in fact, immunized.
Deadly meningococcal bacteria can be spread through kissing, but no one objects to the meningitis vaccine on the grounds that it will suddenly inspire teenagers to start making out. Yet this is exactly what happened to HPV — it got a brand of prosex, not anticancer.
When it introduced Gardasil, Kahan explains, Merck pushed the government for a fast-track approval for girls only, not wanting to wait on data for both sexes (today, young men and boys can also get it). Given pervasive double standards when it comes to sex — it's fine for boys, never okay for girls — having a girls-only STI shot may have helped turn it into a divisive symbol in the culture wars. The abstinence movement had already been highlighting the threat of HPV as a reason to avoid sex. In 2005, the Abstinence Clearinghouse posted on its website, "Premarital sex is dangerous, even deadly. Let's not encourage it by vaccinating 10-year-olds so they think they're safe." Years later, surveys find that parent concerns about promiscuity continue to be one of the big reasons for refusing the vaccine. A study published in the journal Pediatrics deemed these fears unfounded — that sexual activity does not differ between vaccinated and unvaccinated teenagers.
Even if parents don't believe the HPV vaccine is a license for rampant sex, its image as an STI shot still hurts, says Annie-Laurie McRee, of Ohio State University's College of Public Health. When kids are young, parents simply don't perceive a risk. "There's just this feeling that we can wait," McRee says. Then they just never get around to it.
Pediatricians have also been wary. Fewer than one-half said they recommended vaccinating their youngest adolescent patients (when the shot is recommended), according to a study in Pediatrics. "It makes health-care providers uncomfortable," says Gregory Zimet, PhD, of Indiana University School of Medicine. "They feel like they have to discuss it in detail with parents in a way that's quite different than the way they discuss other vaccines."
Merck made one more misstep during its rollout. It launched an intensive lobbying effort with state governments to make the vaccine required for public school. The company tried to win over influential conservatives, choosing as its standard bearer Governor Rick Perry, of Texas. He declared the vaccine mandatory in 2007 by executive order — triggering outcry from critics who pointed out that his former chief of staff was a lobbyist for Merck. Instead of embracing the vaccine, public sentiment soured, distrustful of a government mandate on a product that was fast becoming an emblem of premarital sex. The state legislature overturned Perry's order just two months after it was issued, and Merck suspended its statehouse campaigns because the cancer-prevention aspect of HPV became overshadowed by debate about the company's profit motives.
Suspicions have dogged the vaccine ever since. The list of rumored dangers is seemingly endless: risk of autoimmune disease, seizures, blood clots, even mental retardation. (That last one courtesy of Representative Michele Bachmann, describing an encounter with a random mom who was never identified.) In a controversial show a few months ago, Katie Couric interviewed a mom who believes her daughter died because of the Gardasil shot, as well as Diane Harper, MD, an HPV researcher at the University of Louisville who claims its protection lasts only five years.
It's hard to read about the HPV vaccine without coming across web posts about Dr. Harper, who, while a researcher at Dartmouth Medical School, was involved in the key clinical trials of both Gardasil and Cervarix. (She's not the developer, as a periodically churned blog post claims.) "Initially, I was incredibly excited that this was going to wipe out a disease," she says. Her enthusiasm dampened as she began to question whether the vaccine would offer protection that would last long enough to prevent an infection that comes and goes over a lifetime and leads to cancer in only a small fraction of cases. Today, she encourages women to get regular Pap tests, look at the data, talk to a doctor, and make an educated decision. (According to CDC officials, there's no evidence to support Dr. Harper's claims that the vaccine's protection wears off.)
Here's the central point: So far, doctors have administered more than 50 million doses of the HPV vaccine, and no serious side effects have been found. Health crises, including sudden, unexplained deaths, do happen in the general population — even to seemingly healthy teens, usually from preexisting risks that were not known. When these medical tragedies occur just after an immunization, even by chance, the shot becomes the culprit. A Facebook-ready anecdote is born.
Safety studies look for patterns of symptoms beyond what you would expect from random occurrence. And so far, nothing has turned up on the radar. The largest study so far — published in October in the British Medical Journal— found absolutely no risk of serious side effects.
Can the beleaguered vaccine be rescued? Public-health experts are trying, primarily by reaching out to doctors through health departments, professional associations, and word of mouth. Pediatrician Tom Petrusick, MD, of Myrtle Beach, South Carolina, is urging his colleagues to take discussions more seriously. "If you're giving vaccines to prevent diseases we have vaccines for, why not use this one? We're about prevention. That's pediatrics," he says. Indiana University's Zimet says there are efforts to ensure that patients who get the first shot also get the next two.
It may also help that the Affordable Care Act requires the coverage of preventive care and publicly funded vaccine programs, so fewer women may be priced out of the shot — women like Ashley Altman of Savannah, Georgia, who was offered the vaccine in 2008 when she was 24. "There was no way I could come up with that kind of money," she says. A year later, she was diagnosed with a potentially invasive form of cervical cancer.
By the time she was offered the vaccine, Altman was already having sex and already a mother. Since the immunization won't affect the virus after the fact, she didn't know it would do her any good even if she could afford it. Dr. Schuchat says the CDC advises young women to get immunized even if they could've been exposed to HPV, because they may not have picked up one of the cancer-causing strains yet. However, "the value of getting it decreases with age and with the chance of exposure." Age 26 is the cutoff, because by then, there's a high likelihood of infection.
As Altman's cancer continues to advance, she faces a hysterectomy to remove her cervix. The choice may be easier because she's already had children — including an 11-year-old boy who just got his first HPV shot. "It's not a risk that I want to take with my son," she says. "Who's to say one day when he gets married — if he were to have HPV — he would not then give it to his wife? I don't want somebody else to go through the same thing."
What You Need To Know About HPV and Sex
Q: If I get it, will I have it forever?
A: "While most people clear HPV infections within a year or two, we don't know if that means the virus is completely gone or if it's just dormant," says Jeffrey Klausner, MD, of UCLA. "Still, having HPV is much less likely to hurt you if you get regular cancer screenings."
Q. Can I know who gave it to me?
A. "There's no HPV test for men, and when a woman tests positive, we don't know if she got it a month ago or two years ago, so determining who gave it to you is pointless," says Dr. Klausner. All guys should get the HPV shot.
Q. Are fever blisters on the mouth HPV?
A. No. Fever blisters are caused by the herpes virus and have no relation to HPV.
Q. What about warts?
A. Of the 79 million Americans with HPV, only 1 percent have visible genital warts, according to the CDC. If you are one of the unlucky few, they are treatable with medication or surgical removal.
Q. What are my odds of getting cervical cancer?
A. Really low once you know you have HPV. Thanks to regular Pap testing, cervical cancer has gone down more than 50 percent in 30 years. "The vast majority of pre can cers can be caught and treated before they turn into invasive cancer," says Christina Chu, MD, associate professor of obstetrics and gynecology at the Hospital of the University of Pennsylvania.
Q. Will HPV make it harder to get pregnant?
A. No, but procedures that remove infected tissue from your cervix, like LEEP and cone biopsies, may increase your risk for preterm births. That's why you should discuss the risks with your doctor before these procedures.
Q: So, can I still have sex?
A: Sure! (Unless you have an outbreak of genital warts, which is rare but makes you extra contagious.) "Most everyone will get HPV," says Dr. Chu. "Our concern is that it not turn into cancer."
Q: Can a virgin have HPV?
A: Yes, says Dr. Chu. "HPV is transmitted through intercourse but also through skin-to-skin contact from intimate touching, rubbing, and even sex toys."
Q: Do condoms protect me?
A: Because HPV is spread through skin-to-skin contact, condoms don't provide 100 percent protection, but they do drastically lower your risk.
Q: Does having HPV make other STIs more likely?
A: The cell changes caused by HPV that break down tissue in the vagina and cervix could make you more vulnerable to HIV.
Q: Will having only anal sex help me avoid HPV?
A: Nope. "Virtually all STIs can be transmitted during vaginal, oral, and anal sex," says Dr. Klausner. "But because the same strains of HPV can cause cervical, oral, and anal cancer, the vaccine helps protect you from all of them."
Q: Can I make oral safer?
A: Being a nonsmoker and practicing good mouth hygiene lower the risk of getting HPV from oral sex, a study in Cancer Prevention Research shows.
Q: Do I have to tell my guy?
A: Your call. Docs say it wouldn't make a difference for his health — he can't get tested for HPV or screened for HPV-related mouth and penile cancers. But he can spread HPV, so use condoms.
Additional reporting by Kelly Mickle
Photo credit: Getty/Gallerystock
Related Stories:
>> The Complete Idiot's Guide to Women's Health
>> HPV 101: 11 Facts You Need To Know
From Cosmopolitan.com. Visit Amazon Beauty Ceneter here
